Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2558

2. Registrant Information.

Registrant Reference Number: DAS12091800

Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc.

Address: Suite 2100, 450 - 1 Street S.W.

City: Calgary

Prov / State: Alberta

Country: Canada

Postal Code: T2P 5H1

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

18-SEP-12

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

16-SEP-12

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No. 14879      PMRA Submission No.       EPA Registration No.

Product Name: Lorsban 4E Insecticide

• Active Ingredient(s)
  • CHLORPYRIFOS

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

A homeowner hired a professional exterminator to spray the inside of their house for fleas. The homeowner saw the applicator mix 500 to 750 mL of a thick white product with 4 to 5 Litres of water. The solution was then applied throughout the house. The smell was very strong. The homeowner noticed a 10 L plastic jug in the truck with a "Lorsban 4E" label on it. He confronted the applicator about it but the applicator strongly denied that he used Lorsban. The smell was very strong at first, but diminished after 36 - 48 hours.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

5. Was medical treatment provided? Provide details in question 13.

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

What was the activity? Product applied in a home by exterminator

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

A homeowner hired a professional exterminator to spray the inside of their house for fleas. They were initially going to use Dragnet and then told the homeowner they were going to use a newer, more effective product. The homeowner saw the applicator mix 500 to 750 mL of a thick white product with 4 to 5 Litres of water. The solution was then applied throughout the house. The smell was very strong. The homeowner noticed a 10 L plastic jug in the truck with a "Lorsban 4E" label on it. He confronted the applicator about it but the applicator strongly denied that he used Lorsban. The smell was very strong at first, but diminished after 36 - 48 hours. The wife of the homeowner complained of a headache on the first day, either from the smell or from the stress of the situation. The headache went away within 24 hours.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.